Background Although intake of fruits and vegetables seemed to have a protective effect on bone metabolism, its effect on fractures remains uncertain. Methods A systematic review of randomized controlled trials (RCTs) and cohort studies (PROSPERO: CRD42016041462) was performed. RCTs and cohort studies that evaluated the combined intake of fruits and vegetables in men and women aged over 50 years were included. We considered fractures as a primary outcome measure. Changes in bone markers were considered as secondary outcomes. The search strategy included the following descriptors: fruit, vegetables, vegetable products, bone and bones, bone fractures, postmenopausal osteoporosis, and osteoporosis. PubMed, Embase, and Cochrane Library were the databases used. The appraisal of the studies was performed by two independent reviewers, and discussed and agreed upon by both examiners. The data extracted from the RCTs and cohort studies were summarized separately. The risks of fractures were combined across studies using random models. Bone resorption marker (CTx) was summarized with standardized mean differences. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to evaluate the strength of recommendations. Results Of the 1,192 studies screened, 13 articles were included in the systematic review and 10 were included in the pooled analysis (6 cohort studies and 4 RCTs). The six cohort studies included in the meta-analysis included a population of 225,062. The pooled hazard ratio (HR) (95% confidence interval (CI)) of the hip in five studies was 0.92 (0.87, 0.98). Its heterogeneity was moderate (I 2 = 55.7%, p = 0.060), GRADE ( ⊕⊕⊕ O). Two cohort studies evaluated the risk of any fracture; the HR was 0.90 (95% CI: 0.86–0.96), with aheterogeneity of 24.9% (p = 0.249, GRADE ( ⊕⊕⊕ O)). There was no association between the bone resorption marker CTx and 3 months of fruit and vegetable intake evaluated by four RCTs, GRADE ( ⊕⊕ O O). Conclusion There was an association between the increase of at least one serving of fruits and vegetables per day and decreases in the risk of fractures. The level of evidence for this association is moderate.

RESUMO:O objetivo deste estudo foi identificar os desafios da Atenção Primária à Saúde e Terciária nos serviços de saúde de um município do sul do Brasil. Estudo descritivo-exploratório, de abordagem qualitativa, realizado com equipe multiprofissional. Os dados foram coletados entre julho e agosto de 2014, utilizando-se a entrevista semiestruturada. Os resultados foram organizados em duas categorias temáticas: Dificuldade de articulação nos serviços de saúde e o trabalho solitário. A falta de comunicação entre os trabalhadores dos serviços, o desconhecimento sobre os serviços da rede, a carência de educação permanente, a ausência de retorno dos serviços e a falta de responsabilização dos profissionais envolvidos no cuidado foram destaque, o que fragiliza os processos de referência e contrarreferência. DESCRITORES: Serviços de saúde; Assistência integral à saúde; Referência e consulta; Equipe de assistência ao paciente. DESAFIOS CHALLENGES OF REFERRAL AND COUNTER-REFERRAL IN HEALTH CARE IN THE WORKERS' PERSPECTIVEABSTRACT: This study's objective was to identify the challenges of Primary and Tertiary Healthcare in the health services of a municipality in the South of Brazil. It is a descriptive-exploratory study, with a qualitative approach, undertaken with the multi-professional team. The data were collected between July and August 2014, using semistructured interviews. The results were organized in two thematic categories: Difficulty in articulation in the health services and the solitary work. The lack of communication between the services' workers, lack of knowledge regarding the services in the network, lack of continuing education, the absence of feedback from the services and the lack of responsibilization of the professionals involved in the care were highlighted, which weakens the processes of referral and counter referral. El objetivo del estudio fue identificar los desafíos de la Atención Primaria a la Salud y Terciaria en los servicios de salud de un municipio del sur de Brasil. Estudio descriptivo exploratorio, de abordaje cualitativo, realizado con equipo multiprofesional. Los datos fueron obtenidos entre julio y agosto de 2014, utilizándose la entrevista semiestructurada. Los resultados fueron organizados en dos categorías temáticas: Dificultad de articulación en los servicios de salud y el trabajo solo. La falta de comunicación entre los trabajadores de los servicios, el desconocimiento acerca de los servicios de la red, la carencia de educación permanente, la ausencia de retorno de los servicios y la falta de responsabilización de los profesionales involucrados en el cuidado fueron destaque, lo que debilita los procesos de referencia y contrarreferencia. DESCRIPTORES: Servicios de salud; Asistencia integral a la salud; Referencia y consulta; Equipo de asistencia al paciente.

OBJECTIVE To determine the predisposing factors for PI in patients hospitalized after stroke. METHODS This 7-day longitudinal study followed up with patients hospitalized after stroke. Assessments included mobility, nutrition, and the presence of dysphagia and anemia. The nutrition evaluation was based on anthropometric, biochemical, and dietary determinants. Pressure injury (PI) risk was assessed via the Braden Scale. Mann-Whitney and Kruskal-Wallis tests were applied. RESULTS Patients who were bedridden showed a greater risk of PI development upon admission (P = .004) and 7 days later (P < .001) compared with patients who could ambulate. Patients who were not dysphagic presented a lower risk of PI development in relation to patients who were dysphagic on admission (P = .047) and 7 days later (P < .001). On admission, patients with good and average diet acceptance had a lower PI risk (P = .002; P = .034) compared with those with a low acceptance. Body mass index was lower in patients at a high risk of developing PI compared with those at moderate risk (P = .02). Hemoglobin and hematocrit were statistically lower among patients who were at high risk of PI compared with patients who were low risk. CONCLUSIONS Predisposing factors such as immobility, dysphagia, low diet acceptance, nutrition risk, and anemia are associated with a greater risk of PI development.